Childhood obesity is a public health concern in Canada. (1) Obese children are at a greater risk of health complications later in life, including premature death, (2) however treatment is challenging due to its complex etiology. (3) Evidence demonstrates that intervention programs should be family-centered and focus on physical activity (PA), diet and lifestyle behaviours. (3) Furthermore, these programs should include discussions concerning self-monitoring, goal setting, problem solving, and relapse prevention. (3)

Current Canadian clinical practice guidelines for the management of childhood obesity suggest that interventions be administered by primary care providers or through a weight management program. (4) Readily available educational resources include Canada's Food Guide (5) and PA guidelines. (6) However, a recent review of Canadian primary care providers estimates that only 50% of providers discuss weight management with families and that information is simply offered, not individualized. (7) Furthermore, there exist few family-centered weight management programs that have utilized or evaluated these Canadian resources as the primary treatment of childhood obesity. (7)

In Canada, it is recommended that children 4-8 years of age consume two servings of milk and alternatives/day, (5) however only one third meet this recommendation. (8) While a milk serving is defined as 250 ml, servings of alternatives such as yogurt are dependent on the product. Increasing servings of milk to 3-4 servings per day has positive effects on weight management in children. (9-12) However, these randomized controlled trials ranged from 16 weeks to six months in duration and thus the sustained benefits are not clear. (10-12) Physical activity recommendations are 60 minutes of moderate-to-vigorous PA seven days per week, with weight-bearing activities performed during three of those days. (6) Physical activity, specifically weight-bearing PA (i.e., skipping, dancing or soccer), not only affects body composition, but also strengthens muscles and bones. (6)

To date, there are no trials that use current dietary and PA recommendations as a basis of an intervention program and explore the effects of increased milk products and weight-bearing PA on changes in adiposity in children. The primary objective of the randomized controlled trial (RCT) was to test the effects of a family-centered lifestyle intervention using Canada's Food Guide and PA guidelines to reduce body mass index (BMI)-for-age z-scores (BAZ) in overweight and obese (OW/OB) children. It is hypothesized that children randomized to increased milk and alternatives and focus on daily weight-bearing PA will have a lower BAZ at 12 months compared to children counselled to meet current Canadian dietary and PA recommendations, and the control group.

METHODS

Ethics statement

Ethics approval was obtained from the McGill University Faculty of Medicine Institutional Review Board, Lester B. Pearson School Board (Montreal, QC) and the English Montreal School Board (Montreal, QC) [Trial registration: ClinicalTrials.gov: NCT01290016].

Setting

Participants were recruited (January 2011-January 2013) for the McGill Youth Lifestyle Intervention with Food and Exercise (MY LIFE) from Montreal (QC). The study was conducted at the Mary Emily Clinical Nutrition Research Unit (Sainte-Anne-de-Bellevue, QC). Details on the study protocol, including recruitment strategy, are published elsewhere. (13)

Study population

Eligible participants included healthy children 6-8 years of age with no known illnesses, classified as overweight or obese according to the World Health Organization (WHO) BMI cut-off criteria. (14) At baseline, parents completed a consent form; children completed an assent form.

Study design

At baseline, children were randomized (allocation ratio 1:1:1) to one of three groups (Standard [StnTx], Modified [ModTx] or Control [Ctrl]) by a computer-generated list and stratified by sex and BMI percentile-for-age (overweight: 85-97 percentile; obese: >97 percentile). (14) Study measurements occurred every three months for one year. Pubertal stage was reported by caregiver using Tanner Staging images (15) and confirmed using fasting serum concentrations of luteinizing hormone and estradiol. Caregivers completed a socio-demographic questionnaire and self-reported their height and weight.

Intervention

All families received the same standard teaching of Canada's Food and PA Guidelines at baseline. StnTx and ModTx participated in six monthly interventions with a dietitian; details concerning the interventions have been published elsewhere. (13) Briefly, interventions were family-centered and focused on overall lifestyles, including discussions concerning both diet and activity. Specifically, all sessions included different educational components that covered various diet and PA topics. Despite each family receiving the same teachings, dietitians focused on individualizing goals and relapse prevention techniques using Health Canada's SMART Goals approach. Further, the dietitian facilitated discussions concerning self-monitoring and problem solving in order to successfully meet diet and PA recommendations. All sessions were conducted in either English or French and were designed to be appropriate for the Level 1 literacy level to ensure that participants and all family members irrespective of education would be able to actively participate in and understand the sessions. This ensured that goals were attainable and realistic given the family-specific needs and capabilities.

The dietitian guided families to either provide their child with two servings (StnTx) or four servings (ModTx) of milk and alternatives/day, preferably consuming products with lower percentage of milk fat (%MF) (i.e., 1%MF milk, 15%-18%MF cheese, 1%-2%MF yogurt). Both groups were encouraged to meet current PA guidelines (60 minutes of moderate-to-vigorous activity/day) and limit screen time (<2 hours/day);daily weight-bearing activities (i.e., skipping rope, jumping types of activities) were emphasized in ModTx. The Ctrl received the same interventions after completing the study.

Main measurements and outcomes

At each visit, children presented having fasted the previous 12 hours. Weight was measured using a standard balance beam scale (Detecto, Webb City, MO, USA); height was measured to 0.1 cm using a stadiometer (model 213, SECA Medical Scales and Measuring Systems, Hamburg, Germany). BMI (kg/[m.sup.2]), BMI-for-age z-scores (BAZ) and height-for-age z-scores (HAZ) were computed using the WHOAnthroPlus Software. (16) Waist circumference (WC) was measured to the nearest 0.1 cm at the umbilicus. (17)

Body composition was assessed using whole body dual-energy X-ray absorptiometry (DXA) (Hologic Discovery A fan beam with APEX software [version 13.3:3], Hologic Inc., Bedford, MA, USA) for fat mass (FM; kg), lean mass (LM; kg), percent body fat (%BF; %), trunk fat mass (kg), android/gynoid ratio and fat mass index (FMI; kg/[height.sup.2]). FMI estimates excess fat versus the conventional BMI that measures excess weight. (18) Values were compared to the Hologic normative database (National Health and Nutrition Examination Surveys). Quality assurance scans using Hologic lumbar spine phantom no. 14774 were performed at each visit, with coefficients of variability of 0.5% for bone mineral content and 0.3% for bone mineral density.

Biochemistry

Every three months, blood samples were obtained by venipuncture between 8 am and 12 pm, following 12 hours fasted. Samples were analyzed for luteinizing hormone, estradiol, and other health indicators, via auto-analyzers (Beckman Access and Beckman DXC600, CA, USA) at the Montreal Children's Hospital Clinical Chemistry laboratory (Montreal, QC).

Valid biomarkers of dairy fat were used to complement dietary records as a measure of compliance to the increased milk and alternative intervention (ModTx). (19,20) Myristic (14:0), pentadecanoic (15:0), heptadecanoic (17:0) and stearic (18:0) acids were measured in red blood cells (RBC) using a gas chromatography (Varian CP-3800, Walnut Creek, CA, USA) with a flame-ionization detector. RBC lipids were prepared using direct methylation; (21) recovery was determined to be 99.8% based on added C21:0 (Nu-Chek Prep, Inc., Elysian, MN, USA). Chromatogram peaks were identified against standard GLC 461 (Nu-Chek Prep, Inc., Elysian, MN, USA); fatty acids were expressed as percentage of total fatty acids, with coefficients of variation ranging from 4.9% to 15.4%.

Dietary intake and physical activity

Dietary intakes were assessed using three-day food diaries (3DFD). Caregivers recorded dietary intake for three non-consecutive days including a weekend day, as instructed by a registered dietitian. The first 3DFD was recorded the week after the study visit; all other 3DFD reflected diet prior to study visits. Data were analyzed using Nutritionist Pro software (Axxya Systems, Stafford, TX, USA) and the Canadian Nutrient File 2010b. Intakes were analyzed according to Canada's Food Guide (CFG) food groups. Children were classified as not meeting, meeting or exceeding CFG recommendations.

Physical activity was captured using the Physical Activity Questionnaire for Children [PAQ-C] (22) modified to include measures of time and intensity [mPAQ-C]. The mPAQ-C, completed by caregivers, reflected the child's PA the week prior to study visits and included questions concerning total screen time per week.

Statistical analysis

Data were analyzed using SAS version 9.3 (SAS Institute, Cary, NC, USA). Based on previous studies, (12,23) 116 overweight or obese children were needed to provide 80% power at a 5% significance level (two-sided) to detect a mean change in BAZ of -0.2 (SD 0.3) at 12 months. Estimating a 10% drop-out rate, 39 children were needed per group. Differences at baseline among groups were assessed using analysis of variance (ANOVA). Mixed-model ANOVAs were used to determine group and time interactions for anthropometry, body composition, dietary and PA measures with Tukey-Kramer adjustments. Similar models excluding time were examined to test changes ([DELTA]) at six months and 12 months from baseline for BAZ, %BF, WC, trunk fat mass and FM. All models were tested for covariance structure using best-fit statistics. Fixed effects included group, time, BMI classification (i.e., overweight or obese) and gender; random effects included age, subject nested in group, family income, and parent education. Associations between measured RBC fatty acids and milk and alternative intakes were analyzed by Spearman correlations. Analyses were performed as intent-to-treat and presented as mean [+ or -] standard deviation, unless otherwise noted. Significance was set at <0.05.

RESULTS

Seventy-eight children (7.8 [+ or -] 0.8 years of age) participated in the study (Figure 1). StnTx had families with lower household incomes (p = 0.018) and fathers with lower education (p = 0.005) compared to ModTx and Ctrl (Table 1). Children were prepubescent (Tanner Stage 1) with normal luteinizing hormone and estradiol. The majority of caregivers had self-reported BMI classified as overweight/obese (Table 1).

At baseline, PA reported by caregivers revealed that 21% of children met while 46% exceeded recommendations (n = 71). Weight-bearing PA was performed on average 4.6 [+ or -] 3.3 times/week and screen time was 6.9 [+ or -] 3.2 hours/week.

Intervention effects on anthropometry and body composition

In all groups, HAZ increased at 12 months (p < 0.001);AHAZ was greater in StnTx (p = 0.004) and Crtl (p = 0.013) compared to ModTx (Figure 2A). Both intervention groups decreased BAZ at six months (StnTx: p = 0.017;ModTx: p < 0.0001) and 12 months (StnTx: p < 0.001, ModTx: p < 0.001). However, ModTx resulted in greater reductions in [DELTA]BAZ at six months (p = 0.001) and 12 months (p = 0.001) compared to Ctrl (Figure 2B).

ModTx decreased %BF at six months (p = 0.032) and 12 months (p = 0.018). The [DELTA]%BF from baseline to 12 months showed greater reductions in ModTx (p = 0.034) compared to Ctrl (Figure 2C). At 12 months, Ctrl increased FM (p < 0.001); there was a greater decrease in [DELTA]FM in ModTx compared to Ctrl at six months (p = 0.051) and 12 months (p < 0.001) (Figure 2D). At 12 months, WC increased in both StnTx (p = 0.004) and Ctrl (p < 0.001); the AWC in Ctrl was greater at 12 months (p = 0.002) compared to ModTx (Figure 2E). In Ctrl, trunk fat mass increased at 12 months (p = 0.003); [DELTA] trunk fat mass was greater in Ctrl compared to ModTx at 12 months (p = 0.009) (Figure 2F). At 12 months, Ctrl gained 0.29 kg FM in the android region (p = 0.028); there were no other significant group x time interactions for FM in the gynoid region or android/gynoid ratio. Fat mass index did not significantly change in any group at 12 months. Lean mass increased in all groups at 12 months (p < 0.001) (n = 68; median 3.3 kg, range: -1.0 to 7.6 kg); however [DELTA] lean mass was greater in StnTx (p = 0.001) and Ctrl (p < 0.0001) compared to ModTx at 12 months.

Intervention effects on lifestyle: Diet and physical activity

Fifty (64%) week-1 3DFD were returned. There were no differences for anthropometric or body composition measures between participants who returned 3DFD versus those who did not. Diet did not conform to CFG or differ among groups in proportions below, meeting or exceeding recommendations (Figure 3). However, week-1 intakes differed (1 x 1 comparisons): ModTx consumed ~340 kcal/day less compared to Ctrl (p = 0.018) (Table 2) while StnTx (p = 0.025) and ModTx (p = 0.014) consumed less protein compared to Ctrl (Table 2).

Only 41% and 33% of 3DFD were returned at six months and 12 months respectively (Table 2); there were no differences among groups for macronutrient intakes. Similarly, diet analyzed by food group servings did not differ among or within groups over time after age adjustments. Data analyzed categorically to describe dietary intakes as percentage below, meeting or exceeding the food groups are presented in Figure 3. At 12 months (n = 24), fruit and vegetable recommendations were met by 30% of StnTx and 29% ModTx, but remained at 0% for Ctrl (Figure 3). Grain product intakes were met by 20% StnTx, 14% ModTx and 0% Ctrl (100% exceeded recommendations in Ctrl). Thirty percent StnTx, 43% ModTx and 29% Ctrl met milk and alternative recommendations. Finally, 50% StnTx, 57% ModTx and 57% Ctrl met the meat and alternative recommendations.

Saturated fatty acids were analyzed at baseline (n = 65), three months (n = 35) and six months (n = 52) as an objective measure of compliance to the milk and alternative intervention. At three months, there were no differences in C15:0 among groups. At six months, there was a decrease (0.04%) in C15:0 in ModTx (p = 0.049). Paired C15:0 values to 3DFD (n = 8) at six months showed no relationship to total dairy intake (rho = 0.26; p = 0.547). Although C17:0 decreased (0.09%) in ModTx from baseline to six months (p = 0.036), C17:0 did not associate with dairy intakes at any time. C14:0 decreased (0.07%) in ModTx at six months (p = 0.053);at three months, C14:0 positively associated with dairy intake in Ctrl (n = 4;rho = 1.0;p < 0.0001). Finally, C18:0 decreased in Ctrl at three months (1.38%, p = 0.005) and six months (0.93%, p = 0.038);C18:0 did not associate with dietary intake.

PA assessed by caregivers did not change from baseline. At six months (n = 68), 25% of children met while 54% exceeded recommendations. Similarly, at 12 months (n = 72), 26% met while 53% exceeded PA targets. There were no significant differences throughout the study for activities classified by intensity or type (weight-bearing) as well as time spent engaged in screen time. Average screen time per week at 12 months was 6.5 [+ or -] 3.1 hours/week.

DISCUSSION

This study demonstrated that children who participated in a family-centered lifestyle intervention that was based on current health guidelines sustained losses in adiposity: StnTx and ModTx attained greater decreases in BAZ compared to the control group. However, ModTx also achieved losses in %BF, whereas at 12 months, Ctrl increased WC and trunk fat mass. Simply providing dietary and physical activity guidelines with a brief education at baseline to the Ctrl group did not reduce obesity in any way.

The interventions used in this study were based on current Canadian guidelines but allowed for individualization and included caregivers. After baseline education sessions, both StnTx and ModTx had lower energy intakes compared to Ctrl, showing early signs of success. Furthermore, irrespective of intervention group, at 12 months both StnTx and ModTx were closer to meeting CFG recommendations compared to Ctrl. This study yielded similar results to those of other studies: when diet and PA goals are realistic and attainable, treatment groups experience a decrease in BAZ (12,24) while control groups experience an increase. (25) Similarly, the magnitude of reductions in BAZ were greater in children randomized to higher dairy intakes, (12) however unique to this study was the addition of weight-bearing PA.

To our knowledge, this was the first intervention in obese children to include a biochemical analysis of saturated fatty acids to complement dietary intake assessments. (19,26) Although ModTx were guided to increase servings of dairy, C15:0 decreased at six months. The interventions in this study focused on choosing lower %MF options, and although the percentage of children meeting the milk and alternative recommendations in the ModTx increased from 21% to 43% at 12 months, the decrease in C15:0 suggests children were possibly consuming diets with lower %MF. (26) Furthermore, C15:0 is found in ruminant meat. (19) At 12 months, all children in the ModTx were either below (43%) or meeting (57%) the meat and alternative recommendation compared to 74% exceeding the recommendation at baseline. Other studies have shown moderate correlations (r = 0.45-0.46) of C15:0 with dairy fat from dietary assessment in adults (20) and children. (19) In this study, the dietary assessments were underpowered, thus limiting similar analyses. Future RCTs are warranted to evaluate these biomarkers and associations with different percentages of milk fat. (27)

Strengths and limitations

Interventions aimed at obese children often face many challenges with recruitment and follow-up. There is evidence to suggest that caregivers may be reluctant to enrol their OW/OB child in an intervention that targets weight due to possible adverse effects. (23) Our study focused on developing a safe, non-judgemental environment for children, which is evident by the high retention rate (94%). Nevertheless, this study has a small sample size below target despite various recruitment efforts and a lengthy recruitment period. Additionally, there were imbalances in family income and father's education. However, we accounted for these imbalances in our statistical analyses. Further, we did not survey number of siblings in our questionnaires, which may impact or influence the child's success. However, the interventions were designed to address any barriers or limitations to meeting goals that may arise specifically due to the challenges of the family dynamics (i.e., single parent versus dual; single child versus siblings). As seen in studies of OW/OB children, (28) this study had a low return of diet records by parents, limiting dietary intake analyses. Although mean intakes at 12 months appear similar, dietary data presented as below, meeting or exceeding the CFG recommendations suggest that monthly interventions helped children attain diets closer to Canadian guidelines. Similarly, PA was subjectively assessed by caregivers. Given the obesogenic nature of the parents participating in the study, it is possible that PA levels were overestimated, and/or children's perceptions of intensity or duration of activity were not accurate. (29) The relationships between PA and anthropometry thus require confirmation using more objective assessments. We therefore caution interpretation of our PA data. Objective measures of PA by accelerometer or pedometer are more valid and should be used with OW/OB children. (30) Finally, the study design did not permit for distinguishing the effects of either dietary (increased milk and alternatives) or PA (weight-bearing PA) on benefits of reducing adiposity as we did not use a step-wise approach to adding these during the interventions.

CONCLUSION

This study suggests that Canadian dietary and PA guidelines are suitable to form the basis of treatment programs for OW/OB children. In order to achieve and sustain goals, interventions need to be realistic for the participating children and caregivers. A follow-up study is warranted to evaluate whether these changes were sustained, an important first step in achieving healthy habits prior to adolescence and adulthood.

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Received: January 14, 2016

Accepted: July 16, 2016

Tamara R. Cohen, RD, MSc, [1] Tom J. Hazell, PhD, [2] Catherine A. Vanstone, RN, MSc, [1] Celia Rodd, MD, MSc, [3] Hope A. Weiler, RD, PhD [1]

Author Affiliations

[1.] School of Dietetics and Human Nutrition, McGill University, Sainte-Anne- deBellevue, QC

[2.] Department of Kinesiology and Physical Education, Wilfrid Laurier University, Waterloo, ON

[3.] Children's Hospital, University of Manitoba, Winnipeg, MB

Correspondence: Hope A. Weiler, PhD, School of Dietetics and Human Nutrition, Macdonald Campus, McGill University, 21111 Lakeshore Road, Sainte-Anne-de- Bellevue, QC H9X 3V9, Tel: 514-398-7905, E-mail: hope.weiler@mcgill.ca

Acknowledgements: This study was supported by an operating grant from the Dairy Research Cluster Initiative (Agriculture and Agri-Food Canada, Dairy Farmers of Canada, and the Canadian Dairy Commission). Cohen is supported by Frederick Banting and Charles Best Canada Graduate Doctoral Award (Canadian Institutes of Health Research). Weiler is supported by funding from the Canada Research Chairs Program and the Canada Foundation for Innovation.

The authors acknowledge Sarah-Eve Loiselle and Popi Kasvis for their help with the interventions; Nicolas Kim for his assistance with DXA measures; Caitlin Ellery for sample processing and Sandra Dell'Elce for assisting with blood sampling. Dr. Hugues Plourde is acknowledged for his guidance with conceptualizing the behavioural components of the interventions in the study.

Conflict of Interest: None to declare.

Table 1. Participant baseline characteristics according to randomization

Variable                        StnTx                    ModTx

Age (years)            7.7 [+ or -] 0.8 (25)    8.1 [+ or -] 0.7 (25)
Ethnicity,                    71% (17)                 92% (22)
  white (%, n)
Gender, female (%, n)         56% (14)                 60% (15)
Family income                  38% (8)                 81% (17)
  >$75,000/year
  (%, n) ([dagger])
Education, higher
education ([double
dagger])
  Mother (%, n)               79% (19)                 84% (21)
  Father (%, n)                40% (9)                 77% (17)
Parental self-report
BMI ([section])
  Mother, BMI >25 kg/         68% (13)                 70% (14)
    [m.sup.2] (%, n)
  Father, BMI >25             93% (13)                 83% (15)
    kg/[m.sup.2]
    (%, n)
Waist circumference    81.3 [+ or -] 8.4 (25)   81.6 [+ or -] 8.7 (25)
  (cm)
Weight z-score          3.4 [+ or -] 1.3 (25)    3.0 [+ or -] 1.2 (25)
Height z-score          1.1 [+ or -] 0.9 (25)    1.1 [+ or -] 0.9 (25)
BMI (kg/[m.sup.2])     25.2 [+ or -] 3.9 (25)   24.1 [+ or -] 2.8 (25)
BAZ                     3.6 [+ or -] 1.4 (25)    3.1 [+ or -] 1.0 (25)
BMI classification              2/25                     1/25
  OW/OB ([section])
Lean body mass (kg)    25.5 [+ or -] 3.8 (25)   26.1 [+ or -] 4.2 (25)
Total fat mass (kg)    17.2 [+ or -] 5.6 (25)   15.9 [+ or -] 3.5 (25)
Percent body fat (%)   38.5 [+ or -] 5.5 (25)   36.8 [+ or -] 5.6 (25)
Fasting glucose         4.9 [+ or -] 0.5 (18)    4.8 [+ or -] 0.4 (21)
  (mmol/L)
Insulin (pmol/L)       53.1 [+ or -] 28.5 (18)  44.8 [+ or -] 24.9 (19)
Total cholesterol       4.2 [+ or -] 0.7 (19)    5.5 [+ or -] 6.2 (21)
  (mmol/L)
HDL (mmol/L)            1.2 [+ or -] 0.4 (18)    1.2 [+ or -] 0.3 (21)
LDL (mmol/L)            2.5 [+ or -] 0.7 (18)    2.5 [+ or -] 0.7 (21)
Triglycerides           1.1 [+ or -] 0.7 (19)    0.9 [+ or -] 0.5 (21)
  (mmol/L)

Variable                        Ctrl                 Total sample

Age (years)            7.7 [+ or -] 0.8 (28)    7.8 [+ or -] 0.8 (78)
Ethnicity,                    81% (22)                 81% (78)
  white (%, n)
Gender, female (%, n)         57% (16)                 57% (78)
Family income                 57% (15)                 59% (68)
  >$75,000/year
  (%, n) ([dagger])
Education, higher
education ([double
dagger])
  Mother (%, n)               85% (23)                 83% (76)
  Father (%, n)               81% (17)                 65% (66)
Parental self-report
BMI ([section])
  Mother, BMI >25 kg/         61% (13)                 70% (61)
    [m.sup.2] (%, n)
  Father, BMI >25             94% (16)                 88% (49)
    kg/[m.sup.2]
    (%, n)
Waist circumference    80.7 [+ or -] 9.1 (28)   81.2 [+ or -] 8.6 (78)
  (cm)
Weight z-score          3.1 [+ or -] 1.0 (28)    3.2 [+ or -] 1.2 (78)
Height z-score          1.2 [+ or -] 0.9 (28)    1.1 [+ or -] 0.9 (78)
BMI (kg/[m.sup.2])     24.1 [+ or -] 3.2 (28)   24.4 [+ or -] 3.3 (78)
BAZ                     3.2 [+ or -] 1.1 (28)    3.3 [+ or -] 1.2 (78)
BMI classification              3/28                     6/78
  OW/OB ([section])
Lean body mass (kg)    25.6 [+ or -] 4.3 (28)   25.7 [+ or -] 4.0 (78)
Total fat mass (kg)    15.6 [+ or -] 4.4 (28)   16.2 [+ or -] 4.6 (78)
Percent body fat (%)   36.4 [+ or -] 4.9 (28)   37.2 [+ or -] 4.9 (78)
Fasting glucose         4.8 [+ or -] 0.3 (24)    4.8 [+ or -] 0.4 (63)
  (mmol/L)
Insulin (pmol/L)       36.2 [+ or -] 15.5 (24)  43.9 [+ or -]26.3 (61)
Total cholesterol       4.2 [+ or -] 0.9 (24)    4.6 [+ or -] 3.6 (64)
  (mmol/L)
HDL (mmol/L)            1.3 [+ or -] 0.3 (24)    1.2 [+ or -] 0.3 (63)
LDL (mmol/L)            2.6 [+ or -] 0.9 (24)    2.5 [+ or -] 0.8 (63)
Triglycerides           0.8 [+ or -] 0.4 (24)    0.9 [+ or -] 0.5 (64)
  (mmol/L)

                        F-test
                        or [chi
Variable               square] *  [R.sup.2]  p-value

Age (years)              1.38       0.035     0.258
Ethnicity,              2.44 *       --       0.294
  white (%, n)
Gender, female (%, n)   0.09 *       --       0.958
Family income           7.98 *       --       0.018
  >$75,000/year
  (%, n) ([dagger])
Education, higher
education ([double
dagger])
  Mother (%, n)         0.35 *       --       0.836
  Father (%, n)         10.59 *      --       0.005
Parental self-report
BMI ([section])
  Mother, BMI >25 kg/    0.09       0.003     0.912
    [m.sup.2] (%, n)
  Father, BMI >25        0.14       0.001     0.872
    kg/[m.sup.2]
    (%, n)
Waist circumference      0.07       0.002     0.932
  (cm)
Weight z-score           0.68       0.017     0.507
Height z-score           0.06       0.002     0.945
BMI (kg/[m.sup.2])       0.98       0.025     0.381
BAZ                      1.13       0.029     0.329
BMI classification        --         --        --
  OW/OB ([section])
Lean body mass (kg)      0.16       0.004     0.852
Total fat mass (kg)      0.89       0.023     0.415
Percent body fat (%)     1.43       0.037     0.246
Fasting glucose          1.14       0.045     0.253
  (mmol/L)
Insulin (pmol/L)         2.83       0.089     0.067
Total cholesterol        0.91       0.029     0.407
  (mmol/L)
HDL (mmol/L)             0.51       0.017     0.604
LDL (mmol/L)              0.1       0.036     0.897
Triglycerides            1.78       0.055     0.176
  (mmol/L)

Note: mean [+ or -] standard deviation (n) unless stated
otherwise. StnTx = standard treatment group; ModTx = modified
treatment group; Ctrl = control group; BMI = body mass index
(kg/[m.sup.2]); BAZ = body mass index-for-age z-score; OW =
overweight; OB = obese; HDL = high-density lipoprotein; LDL =
low-density lipoprotein.

* Data analyzed by ANOVA for continuous data (F-test) or
chi-square (x2) for proportions. All tests have two degrees of
freedom.

([dagger]) Total family income was less in StnTx compared to
ModTx and Ctrl (p = 0.017).

([double dagger]) Higher education included university, college
or Cegep. Father's self-reported education was less in StnTx
compared to ModTx and Ctrl (p = 0.004).

([section]) BMI classifications are denoted as n/total.

Table 2. Macronutrient intakes * and Canada's Food Guide Food
Groupst assessed by three-day food diary at week 1, six months
and 12 months

                                           StnTx

                              Week 1               6 months
                              n = 19                n = 10

Total energy (kcal)      1669 [+ or -] 379     1661 [+ or -] 384

Protein (g)              69.7 [+ or -] 13.8    69.6 [+ or -] 13.6
                            ([section])
Fat (g)                  57.5 [+ or -] 23.0    52.6 [+ or -] 15.9
Carbohydrate (g)        223.9 [+ or -] 49.6   232.7 [+ or -] 56.3
Fruits and vegetables     4.9 [+ or -] 1.9      6.6 [+ or -] 2.4
  (servings/day)
Grain products            6.8 [+ or -] 2.0      6.1 [+ or -] 1.8
  (servings/day)
Milk and alternatives     2.2 [+ or -] 1.2      1.6 [+ or -] 0.8
  (servings/day)
Meat and alternatives     1.8 [+ or -] 0.7      2.3 [+ or -] 1.0
  (servings/day)

                               StnTx                 ModTx

                             12 months               Week 1
                              n = 10                 n = 19

Total energy (kcal)      1635 [+ or -] 325     1567 [+ or -] 271
                                               ([double dagger])
Protein (g)              71.7 [+ or -] 7.7     68.4 [+ or -] 10.5
                                                  ([section])
Fat (g)                  53.6 [+ or -] 13.5    53.1 [+ or -] 14.4
Carbohydrate (g)        223.2 [+ or -] 49.6   213.0 [+ or -] 47.3
Fruits and vegetables     4.9 [+ or -] 1.3      4.4 [+ or -] 2.0
  (servings/day)
Grain products            6.1 [+ or -] 1.8      6.2 [+ or -] 1.8
  (servings/day)
Milk and alternatives     1.9 [+ or -] 0.7      2.0 [+ or -] 0.9
  (servings/day)
Meat and alternatives     2.1 [+ or -] 0.6      1.9 [+ or -] 0.6
  (servings/day)

                                            ModTx

                              6 months              12 months
                               n = 12                 n = 7

Total energy (kcal)     1598.7 [+ or -] 337    1449.8 [+ or -] 173

Protein (g)               72.9 [+ or -] 19.2     62.6 [+ or -] 8.2

Fat (g)                   59.3 [+ or -] 14.6    48.59 [+ or -] 13.6
Carbohydrate (g)         199.1 [+ or -] 48.4    198.6 [+ or -] 29.5
Fruits and vegetables      4.9 [+ or -] 2.4       4.0 [+ or -] 1.8
  (servings/day)
Grain products             6.0 [+ or -] 1.8       6.2 [+ or -] 2.0
  (servings/day)
Milk and alternatives      2.3 [+ or -] 1.2       2.8 [+ or -] 1.1
  (servings/day)
Meat and alternatives      1.7 [+ or -] 0.7       1.0 [+ or -] 0.4
  (servings/day)

                                            Ctrl

                               Week 1               6 months
                               n = 12                 n = 8

Total energy (kcal)      1909 [+ or -] 312      1947 [+ or -] 443
                         ([double dagger])
Protein (g)              83.5 [+ or -] 18.3     88.0 [+ or -] 26.3
                            ([section])
Fat (g)                  63.9 [+ or -] 13.6     59.4 [+ or -] 17.5
Carbohydrate (g)        253.8 [+ or -] 42.3    268.7 [+ or -] 59.2
Fruits and vegetables     4.6 [+ or -] 1.9       5.6 [+ or -] 2.3
  (servings/day)
Grain products            7.2 [+ or -] 2.2       6.9 [+ or -] 1.9
  (servings/day)
Milk and alternatives     2.8 [+ or -] 1.6       3.3 [+ or -] 2.5
  (servings/day)
Meat and alternatives     2.2 [+ or -] 0.9       2.0 [+ or -] 0.6
  (servings/day)

                               Ctrl

                             12 months
                               n = 7

Total energy (kcal)      1938 [+ or -] 463

Protein (g)              87.3 [+ or -] 27.7

Fat (g)                  68.8 [+ or -] 17.8
Carbohydrate (g)        248.0 [+ or -] 65.0
Fruits and vegetables     4.9 [+ or -] 1.7
  (servings/day)
Grain products            7.0 [+ or -] 2.0
  (servings/day)
Milk and alternatives     3.6 [+ or -] 2.6
  (servings/day)
Meat and alternatives     2.2 [+ or -] 0.6
  (servings/day)

Note: mean [+ or -] standard deviation.

* Week-1 food diaries were completed the week after the baseline
visit; all subsequent diaries were completed and reflect the week
prior to study visit.

([dagger]) Canada's Food Groups: servings/day.

([double dagger]) p-values for comparison of total energy (kcal)
at week 1 between ModTx and Ctrl (p = 0.018).

([section]) p-values for comparison of total protein (g) at week
1 between Ctrl and StnTx (p = 0.025) and Ctrl and ModTx (p =
0.014).